Strategy and practise of external inspection in healthcare services – a Norwegian comparative case study

Background: We could say that external inspections support improvement of healthcare services, but we know little about how. The aim of this study was to increase knowledge about how county governors, as external inspectorates of healthcare services, support and contribute to improvement through external inspections. Methods: This is a comparative case study where data is based on qualitative interviews and analysis of government documents. Ten semi-structured interviews were conducted with inspectors representing two different county governors in Norway. Data analysis was based on systematic text condensation. Results: The results showed that external inspectors customise their inspection strategy and approach to what they expect will improve practice of the inspected object. Inspectors were careful to practise the enforcement pyramid and appeared very patient when awaiting responses from the inspected object. The county governors had no systematic way to measure the effectiveness of regulatory performance in general or of external inspection in specific. The results confirmed some differences in practises between the two authorities in the study, in terms of attitudes to inspection and standard setting. Conclusion: Compliance strategies were usually considered sufficient to start improvement processes within the inspected object. However, the current practise of external inspections lacked proper methods for measuring effect. For healthcare regulation and inspection in Norway and elsewhere to evolve, there is a need for stronger evidence of the effect of external inspection and better information to act upon when customising strategy and practise in order to legitimize use of public funds.